Personalized practice: Direct primary care grows locally, nationally

Sunday

Direct primary care, a different type of primary care, has been growing across New Jersey, Pennsyvlania and other states.

MOORESTOWN — Geraldine Barksdale, 55, of Lumberton tried almost everything to lose weight. Nothing seemed to work as she hovered closer and closer to 200 pounds.

“I was getting too many different (pieces of) information, and nobody really pinpointed it,” she said. “The last time, I went to the nutritionist, I was like, ‘I need someone that knows my body. Nobody knows me.’”

Then Barksdale started seeing Dr. Steven Horvitz, a Moorestown physician specializing in wellness. Horvitz spent at least two hours each month with Barksdale, taking blood work, examining her diet and the effect it had on her weight, and coming up with a plan that would work. Since October, Barksdale has lost 30 pounds.

“He was the only one that could help me,” she said. “From me talking to him, and all the things that we talked about, I found out that he was more efficient than anybody else that I had talked to.”

The average primary doctor spends only about 15 minutes with patients, according to studies. Yet Horvitz and a growing number of other physicians, both locally and nationally, are eschewing the modern health care model for one known as direct primary care.

Direct primary care allows for patients to pay a monthly fee to visit their primary care doctors, instead of paying a copay each time through an insurance company. Patients can see their doctors as often as they need to, according to Horvitz, and doctors get to spend more time with their patients since they don’t have to follow any numbers or quotas put in place by an insurance company.

“I went into health care primary practice because I like to talking to patients, I like interacting with patients, and I don't like being told what to do so,” Horvitz said. “After having my regular practice, a traditional practice for about 10 to 12 years, the writing was on the wall that said insurance companies are necessary in health care, but they were kind of stepping a little too far into the doctor-patient relationship and I had to find a way to remove them so I could give the care that I needed to. Direct primary care allowed me to do that.”

According to the Direct Primary Care Coalition, a lobbyist group that advocates on behalf of direct primary care, an estimated 330,000 patients are treated through the direct primary care model.

Their numbers are growing, according to Dr. Philip Eskew, founder of “Direct Primary Care Frontier,” a resource for physicians interested in joining the direct primary care movement, and general counsel for the Direct Primary Care Coalition. For Eskew, the practice was something he had been researching both during his time in law school as well as his time in medical school. When he began his research rotation for medical school, he began to realize that no one had put together a map of all of the direct primary care practices across the country.

“I thought ... why don't I try and map them and see what this looks like,” he said. “That was the genesis of the DPC map, which now has around 850 practices. I think the first iteration of it was somewhere around 200, maybe back in 2014. It seems like we're adding about 200 practices a year.”

Dr. Dave Ladley, who opened Octagram Direct Primary Care in Lower Makefield, Pennsylvania, in February, is part of that expansion.

“I came across the DPC movement online,” he said. “I learned the nuts and bolts on how to make it work — it’s like opening any business.”

Ladley said he spent two years after he got out of his residency in 2015 at a traditional practice and noticed that he really had to “move a volume” of patients to make sure the practice was profitable. That’s why he decided to explore the DPC movement and join it, he said.

Horvitz is part of an expanding network of direct primary care doctors in New Jersey, called R-Health, which also has offices in Cherry Hill and Voorhees, Camden County.

“We really fundamentally believe that good primary care is the foundation of great health care,” Amber Van Niekerk, an R-Health spokeswoman, said. “We cap the number of patients our doctors can care for. Where a traditional primary care doctor might have 2,500 to 3,000 patients that they're responsible for caring for, we cap our doctors at 1,000, so it really frees them up to spend more time with each patient.”

Despite some of the benefits doctors and patients say direct primary care provides, it also is adding to a potential physician shortage in the country, according to an article Dr. Edmond Weisbart wrote for the American Academy of Family Physicians.

Because direct primary care caps the number of patients it can see, Weisbart argues that the U.S. would need to "nearly triple" the number of practicing physicians across the country if every doctor adopted the model of taking on a workload of up to 900 patients rather than 2,300. Weisbart also argued that although direct primary care doctors don't have to deal with insurance companies, which can free up their time, that also means they aren't subject to their stricter regulations.

"Although it is easy to scoff at the complexities and increased costs driven by health insurance legislation and regulations, many of those complexities really do protect patients," Weisbart wrote.

Jamie DePolo, who has been with Horvitz for about four years, however, said she appreciated the extra time the doctor can spend with her.

“I feel like I can ask him anything and I never feel like I'm taking up too much of his time,” she said. “He allocates 45 minutes to an hour for a visit, so you can talk about everything.”

DePolo, a science writer who also enjoys CrossFit in her free time, said seeing Horvitz helps reinforce her lifestyle.

“He kind of reinforces the things that I do — I think exercise is very important, I think good nutrition is very important and I think good sleep is very important, and he agrees with that,” she said.

While many doctors would agree with DePolo's lifestyle choices, her ability to discuss new trends in exercise and nutrition as well as updated studies in the field with Horvitz during her visits helps her make sure she stays on the right track.

More patients in New Jersey are receiving access to direct primary care because the state began offering employees and their dependents an opportunity to join a direct primary care office.

“The New Jersey State Health Benefits Program (SHBP) and School Employees' Health Benefits Program (SEHBP) offer employees and their covered dependents the opportunity to join a Direct Primary Care doctor's office at no additional cost,” according to a statement from the New Jersey Department of Pensions and Benefits. “This is available as part of the Horizon Blue Cross Blue Shield and Aetna plans and does not require any changes to your health insurance.”

The coverage is a part of a pilot program that began on April 1, 2016, and is slated to run for three years, after which time the data collected will be evaluated for potential recommendations on how to move forward.

The plans cover the monthly fees for each direct primary care practice, instead of the patient having to pay that out of pocket, although that option is available, Van Niekerk said. For example, Horvitz’s office costs $100 for the first month and $80 a month after for individuals.

“We have no co-pays,” Van Niekerk said. ”So it doesn't matter if someone sees us once a month or 15 times a month. They're never going to pay anything out of pocket when they come in for an appointment.”

Ladley offers a gradual payment for patients, beginning at $50 a month for those between the ages of 20 and 49 up to $100 a month for patients 65 and older.

Ladley said his typical patients are those in the 20-29 age group, “young adults who are not in peak health, their health could use some tuning up and they don’t want to enter middle adulthood as train wrecks.”

Horvitz said he emphasizes a similar practice of “well care” in his office to help stop people from developing costly chronic conditions, such as diabetes or heart disease.

“What happens around 40, 50, 60 years of age — you gain a little weight,” he said. “What happens there, then you get the high blood pressure. And you're prediabetic and then you're diabetic and then you have the heart disease but it all starts going back to a root cause of they're gaining weight.

"Let's figure out the why to prevent it. If we get their weight to a proper level, they're not going to get the high blood pressure, they're not going to get the diabetes, they're not going to get the heart disease. What does that do to their health? It improves it dramatically. What does it do to the cost of health care for them and the system, (it) brings it down dramatically.”

“When the insurance companies came in, again necessary — health care's expensive, we need them — but when they invaded a little bit how much time we could spend with people to keep a practice running, it got in the way,” Horvitz said.

If a patient requires a trip to a specialist or to an emergency room, they still need insurance to cover that.

However, there is more opportunity for expansion, according to Eskew, including legislatively. At least 25 states have adopted some sort of legislation to help define what direct primary care is and help open it up to more people. In Pennsylvania, a House bill providing for direct primary care passed unanimously in September 2017, while the Senate version is before the Banking and Insurance committee.

New Jersey doesn't currently have legislation related to direct primary care, but as a result of this pilot program, the state is planning to evaluate data collected to see how the model could be expanded, if at all.

There’s also been movement on the issue at the federal level. The Centers for Medicare and Medicaid Services announced in April that it was taking public comment for a month on “direct provider contracting,” also known as direct primary care, to see if it should test a direct primary care model within its Medicare and Medicaid programs.

“A DPC model would aim to enhance the beneficiary-physician relationship by providing a platform for physician group practices to provide flexible, accessible and high quality care to beneficiaries that have actively chosen this type of care model,” according to a statement from the Centers.

The Direct Primary Care Coalition wrote a letter supporting the measure.

“Such input from stakeholders like Direct Primary Care practices is essential for meeting the agency’s goal of establishing a new direction for the CMS Innovation Center, focused on reforms that enhance care and provider greater value to the Medicare program,” the letter reads.

On Wednesday, the House of Representatives’ Ways and Means Committee passed the “The Primary Care Enhancement Act,” with a 26-12 vote. The bill would allow almost all practices to have patients with health savings accounts who can then use those accounts to pay for the membership fees, an initiative supported by the Direct Primary Care Coalition.

For patients like Barksdale and DePolo, those measures back up what they’ve been telling their friends.

“(After) I saw (Horvitz) I was like, ‘Woah,’” Barksdale said with a laugh. “When I went back to work, I was like, ‘Ya'll got to go to him, I'm telling you.’ He's going to take all this blood, but he's going to tell you about you.”

Barksdale said she has more energy in her everyday life, thanks to Horvitz.

“I'm energetic,” she said. “I'm always bouncing around when I'm at work — people say, ‘Why you so bouncy?’ and I'm like, ‘I don't know, I've got energy.’ I go help everybody and even at home, I do things — I ride my bike, I go to the gym. I do a lot of things.”

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